Ophthalmologists Have Low Patient Complaint Rates

Tara Haelle

December 09, 2015

Ophthalmologists receive fewer patient complaints overall compared with other physicians, but ophthalmologists working at academic centers receive a disproportionately higher number of complaints within the field, according to a study published online November 13 in Ophthalmology.

"The most common concerns raised against ophthalmologists were related to care and treatment, followed by access and availability, communication, concern for patient and family, and billing concerns," write Sahar Kohanim, MD, MPH, director of patient safety and quality at Vanderbilt Eye Institute in Nashville, Tennessee, and colleagues. "[C]oncerns regarding the safety of the practice environment were rare."

The authors suggest several possible reasons ophthalmologists at academic centers would be at higher risk for complaints than those in smaller clinic settings, including "differential patient complexity; density of high-risk diagnoses in academic practice; different types of bureaucracies; variation in inviting, addressing, or recording complaints, or a combination thereof; or other aspects of organizational culture."

Dr Kohanim's team used the Patient Advocacy Reporting System to compare 2087 unsolicited patient complaints about ophthalmologists with 28,897 complaints about nonophthalmic surgeons and 64,145 complaints about nonophthalmic nonsurgeons, all reported from November 1, 2009, through October 31, 2013.

Among 815 ophthalmologists at 14 academic and 10 nonacademic centers, the majority (63%) had no complaints, whereas 10% of them received 61% of all ophthalmology-related complaints. Overall, ophthalmologists had a rate of 2.56 patient complaints per physician, which is significantly lower than the 5.48 complaints per physician among 5273 nonophthalmic surgeons and the 3.29 complaints per physician among 19,487 nonophthalmic nonsurgeons (P < .001).

"Since unsolicited patient complaints are a known independent predictor of malpractice lawsuits, this implies that we [ophthalmologists] may have a lower malpractice risk as a group," Dr Kohanim told Medscape Medical News.

The researchers also investigated complaints according to practice setting, medical school type (foreign or domestic), physician sex, number of years since medical school graduation, institutional affiliation, and ophthalmology subspecialties. Subspecialty categories included general or comprehensive, cornea, refractive surgery, glaucoma, medical and surgical retina (combined), uveitis, oncology and pathology (combined), neuro-ophthalmology, pediatrics, and strabismus and oculoplastic surgery.

Although female ophthalmologists and younger physicians had a higher risk for patient complaints in a univariate analysis, the associations were no longer statistically significant in the multivariate analysis. The higher proportion of complaints for ophthalmologists at academic medical centers, however, did remain significant after adjusting for confounders, including subspecialty. Physicians at academic centers were 59% more likely to receive complaints than those in other settings (adjusted relative risk, 1.59; 95% confidence interval, 1.4 - 1.78; P < .001).

"More research is needed to sort out why there is this association between academic practice and increased risk of complaints," Dr Kohanim told Medscape Medical News. "We performed an analysis to look at whether there is any variation in terms of actual inviting or recording of patient complaints between the two groups, but when we looked at our highest reporting institutions, we did not find any compelling patterns there," she said.

Among the multiple sensitivity analyses the researchers conducted was one on the patient encounter location associated with each complaint, such as the emergency department or hospital inpatient, outpatient, or other setting, as setting might serve as a proxy for patient case complexity. That analysis also did not reveal any patterns, but it also may have been insufficient to do so, suggested David Wilson, MD, director of the Casey Eye Institute at Oregon Health & Science University in Portland.

"I still think the main reason academic centers would have a higher complaint rate is that they have patients with more complex disease, and those patients will, on average, have...worse outcomes," Dr Wilson told Medscape Medical News. "So they're going to have complaints overall about the medical system because they're not having a very positive experience."

Dr Wilson, who was not involved in the research, pointed out that patients with decreased vision who need glasses or cataracts surgery, for example, can have their needs successfully met in outpatient clinics. Patients with conditions less easily resolvable, such as retinal detachment, complications of macular degeneration, or a hemorrhage resulting from diabetes, are more likely to be referred to academic centers and have poorer overall outcomes, he said.

"The authors tried to get at that by the methodology they had, but I don't think the way they did their study permitted them to come to a conclusion on that," Dr Wilson said. "It was a very, very sophisticated study of patient complaints, but I don't think they could tease out this question of academic vs nonacademic centers because of their methodology."

A study specifically looking at complaints for physicians who work in both academic and nonacademic environments might offer more insights on this point, Dr Wilson said. But he praised this research as a nice example of using big data to help physicians improve the processes of medicine.

"One of the important things in this article is for ophthalmologists to recognize that patient complaints are a surrogate for malpractice risk," he noted. "If they are getting a lot of patient complaints, they should try to address the frequency of complaints before they are...unfortunate and have a malpractice claim against them." Those at academic centers can do the same by taking a look at their processes to try to change the aspects of the practice leading to complaints, he said.

"Looking at patient complaints in a systematic way is a great tool for quality improvement both to identify and address systems issues, improve patient safety and patient outcomes, and to reduce physician malpractice risk," Dr Kohanim said. Vanderbilt contracts with a company that analyzes patient complaints to provide surveillance and feedback, which their physicians find helpful in decreasing their risk, she said.

The authors and Dr Wilson have disclosed no relevant financial relationships.

Ophthalmology. Published online November 13, 2015. Abstract

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